In the past month alone I have spoken with two clients whose in-home rehab therapy was terminated. The first termination was because the provider did not believe further improvement was possible. This decision conflicted with the patient’s doctor’s recommendation and the patient knew she could improve further.
The second involved termination because the provider said there had to be a four week break. In this case the patient would just get stable on his walker and then would lose it during the four week layoff. It was clear he needed rehab therapy to improve or at least maintain the function he obtained.
The simple law of Medicare is this: Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. Medicare B will cover in-home therapy for an indefinite period where the patient’s doctor recommends it and the record shows the need for a professional therapist.
The moral: get a new provider if they terminate therapy and you and your doctor disagree with the termination.
Denials of care are getting more common. Suppose you hear about a new treatment and your doctor agrees to try it. But, your Medicare Advantage insure will not cover the care. What do you do?
As I have written before the patient needs a patient advocate to get good care. A recent article in Forbes again proves the point. The Aetna Medical Director admitted in a lawsuit that he did not review denials of care. Nurses reviewed the files and made the decisions. The case in point involved a rare condition that the doctor did not know the treatment protocols and did not review the patient’s medical record before denying care. Obviously the nurses did not either and the treatment was denied over the patient’s doctor recommendation. You can read the article here.
The moral is clear. When you receive a denial of care, advocate with your doctor. If your doctor agrees that the denial is wrong go up the appeal ladder with your doctor’s support. Eventually the appeal process requires review with the patient’s doctor and that often results in approval.
The dream of the Alzheimer’s patient: reversal of memory loss. There was an enticing report in 2014 that memory loss could be reversed. These were cases of what some called “type 3 diabetes.” In some patients improper processing of carbohydrates led to loss of cognitive function. In those patients improved diet and exercise restored memory function. Other than a prescription of “health living” the study did not offer hope to other memory loss patients.
Recently another study was published that promised renewal of memory processing lost through brain aging. In the Toronto Centre for Addiction and Mental Health study the scientist found that some cases of memory loss involved loss of brain ‘chemicals.’ When these are depleted memory function declines. When restored by additives memory function returned. The study raises the question whether a pill with the necessary brain chemicals can restore memory function in early stage Alzheimer’s patients.
See the report in Science Daily, https://www.sciencedaily.com/releases/2019/02/190214102504.htm
One Commentator cautioned that the “drug” that would be used is related to the class of drugs called benzodiazepines. These can have dangerous withdrawal side effects.
https://www.inverse.com/article/53312-new-treatments-for-memory-loss-aging-alzheimer-s
Yet, the Canadian study gives new hope of finding and reversing the brain process that leads to memory loss in Alzheimer’s. They tell of a day when these brain changes may be prevented or reversed.
Will there soon be a pill that can prevent and restore memory loss? Miracles seem to await, “down the road.”
One of the big stressors for mid-stage Alzheimer’s patients and their caregivers is the inability to do daily routines such as getting dressed. Anybody who has been a daily caregiver for a person with Alzheimer’s knows how the frustration results in a host of difficult behaviors. A therapist can help.
We have written before about how Medicare will pay for therapy even when the patient cannot “improve.” A recent article in the New York Times reports how therapy can help people with cognitive impairment, such as Alzheimer’s Disease, with daily functioning even though their medical condition will not improve. This is a therapy that Medicare can pay for.
Programs in Great Britain and the United States have shown that patients can return to, daily tasks through skilled occupational therapy. The goal of these programs is not to try to delay changes in the brain but delay loss of function. The programs result in improved quality of life for the patients and less stress and difficult behaviors for caregivers to deal with.
In Great Britain Dr. Linda Clare uses methods used to help people with brain injuries. His team has helped patients learn how to use a cell phone, how to warm a prepared lunch, or how to keep track of daily tasks. For example they have the person make a short list of steps and practice a task. They put colored markers on microwaves or washing machines.
In the US Dr. Laura Gitlin’s Tailored Activity Program (T.A.P.) trains occupational therapists how to provide the program in the person’s home.
The use of occupational therapy for patients with cognitive impairment may not be new but its awareness is increasing and techniques are being refined and improved.
The New York Times article is: Dementia May Never Improve, but Many Patients Still Can Learn. You can find it at https://www.nytimes.com/2019/01/04/health/dementia-rehabilitation.html
For further reading on the TAP program see https://learn.nursing.jhu.edu/face-to-face/institutes/NewWay-TAP/index.html
And here is another article on how therapy can help with difficult behaviors, “Occupational Therapy Interventions for People With Alzheimer’s Disease” See https://ajot.aota.org/article.aspx?articleid=2665966
Just this past week the clients I saw about applying for Medicaid to hit almost all the items on this list. Scroll down and see if any happened to you.
1. The nursing home tells the family: “We have no long term care beds. Your spouse/parent will have go to another nursing home.” (False)
This reason occurs when the person is discharged from the hospital for skilled care (rehab) in a nursing home. It is often a nice, expensive looking facility. After a few weeks the family is told the Medicare rehab is over and you will have to find another.
Why get advice? Because most nursing homes in Metro Detroit have long term Medicaid beds. There are two reasons why the corporate office tells its admission employees there are no Medicaid beds, when in fact the whole facility may be licensed for Medicaid. (It happened last week.)
Reason 1: Medicare pays hundreds of dollars a day more per day than the nursing home gets from long term care patient/residents. (That’s true of “private pay” as well.) So the nursing home strategy is to get people in only for the short term Medicare treatment. They have no intention of serving all residents for long term care.
Reason 2: When it comes to long term care, Medicaid pays “wholesale” not retail. That is Medicaid does not pay the $400 per day the nursing home will charge the resident. It pays perhaps two thirds that rate.
2. The nursing home does not tell spouses about their right to part of the savings and resident income.
Under Medicaid a spouse is allowed a share of the money (assets) and the income of the nursing home resident. Let’s use a hypothetical Smith family. They have $40,000 in savings. Mrs. Smith has social security and pension income of $2,700. His wife has Social Security income of $800.
Savings: In 2019 Medicaid allows a “community spouse” is allowed a minimum of $25,284 (and the resident/applicant is allowed $2,000). The Smiths’ have $40,000 in savings. Their “spend down” is $12,718. They could meet the entire amount by prepaying the resident’s funeral at the maximum allowed by Medicaid. $12,770 (2018). They may more realistically spend about $7,000 and use the other $5,718 on other needs or bills. (Caution, see next paragraph on Income.)
Income: The community spouse is not told about her/his right to income support. Medicaid allows the community spouse a minimum monthly of income of $2,057. The spouse is almost always allowed a few hundreds dollars more by “excess shelter expense.” This includes rent or home taxes, insurance and utility expenses. So let’s say a wife has social security income of $800 and her husband has an income of $2,700. If her calculated monthly income allowance, including excess shelter expense is $2,357 then she would get $1,537 of her husband’s income to get to $2,357. His monthly Medicaid co-pay would be the remainder minus $60 for his personal needs and enough to pay any monthly medical insurance premium. If his monthly insurance premium were $303 a month his co-pay would be $700. (Medicaid calls the co-pay the “patient pay amount.”)
3. The nursing does not tell the family about “retroactive” application.
Families are not told that instead of paying the nursing home they may “spend down” and apply the next month for Medicaid. Medicaid’s rule is if you complete the spend down by the end of the month you are eligible the whole month.
Example: Mr. Smith’s Medicare rehab ends on the 10th. The nursing home tells the spouse they want a check for $14,000 to pay to the end of the month and for the next month. What should Mrs. Smith do? Write no check and inform them she will apply for Medicaid to pay his bill. She would then proceed to do the spend down in number 2 above. After she got all the paper work together she could submit a Medicaid application the next month along with a “retroactive application” (a separate form) and have Medicaid pay the entire bill except his monthly co-pay. She would write a check to cover his co-pay. In 2 above it would be $700 and the next month it would be another $700.
4. The family is told they need to spend down by paying the nursing home. (False)
While it is true that a resident is responsible for getting his bill paid, that duty may be satisfied by applying to Medicaid for payment. As relayed above Medicaid requires “spend down” of assets until the resident is eligible. That spending can be anything for the resident or spouse. It need not be for the nursing home. It could be for prepaying the funeral. It could be to fix up the house so that it could sell for a better price. Almost all homes of elders could use a ‘refreshing.” It could be for the purchase of a new car.
5. The family is not told the resident may pay nothing to the nursing home if he will return to home within 6 months.
As relayed above the resident’s spending not only includes spend down of assets but also a monthly co-pay. That monthly co-pay can be waived if a doctor certifies the resident is likely to return to home within 6 months.
6. Bonus! This article is not legal advice. (Don’t rely on articles like this. Verify your situation. Get advice from an attorney!)
MORAL: Medicaid is such a complicated program that very few people know the allowances it makes for the applicant and family. Get advice, save your hard-earned money for those you love and get your benefit from all those taxes you paid for decades.
And, of course, give us a call if you want to be sure you are saving as much as you can, (Hint: 248-356-3500)